RAL Home Meeting Information Registration Hotel Information Travel and Transportation Evening Functions Accreditation Needs and Objectives Program Schedule Rheumatology Alliance of Louisiana Two Woodfield Lake 1100 E. Woodfield Road Suite 350 Schaumburg, IL 60173 (847) 517-7225 (847) 517-7229 firstname.lastname@example.org SIGN UP FOR OUR MAILING LIST Managed by WJ Weiser & Associates, Inc. Registration Rheumatology Alliance of Louisiana 7th Annual Meeting August 9 - 11, 2019 The Westin New Orleans Canal Place New Orleans, LA The deadline for discounted early registration is 7/18/2019. After 7/18/2019 regular registration fees will apply to online and on-site registration. Online registration will be open through 7/29/2019. After this date, on-site registration will be available. Registration Fees are subject to change. To lock in these rates, register now! Please select the category that best describes your status: Select One Rheumatologist Fellow Full Time Administrator Nonphysician Provider Other Other Medical Professional Physician Researcher Resident Student/Trainee Nurse / Nurse Practitioner Industry Employee Fellowship/Residency Program: Expected Graduation Year: Select One 2019 2020 2021 2022 2023 2024 2025 Please Check ALL Areas of Practice Emphasis: (Check all that apply) Ankylosing SpondylitisPsoriatic ArthritisFibromyalgiaRheumatoid ArthritisGoutSclerodermaLupusSjogren’s SyndromeOsteoarthritisDoes Not Apply How did you learn about this conference? Calendar/Monthly ListingRegistration Brochure MailerEmail Registrant Information Address Type: HomeOffice Membership Become a member of RAL today for $50 and receive a discount on your meeting registration. Physicians, Nurse Practitioners, or Physician Assistants residing or practicing in Louisiana qualify for membership in RAL. Residents and Fellows receive free membership. Physician $50 Nurse Practitioner $50 Physician Assistant $50 Fellow $0 Resident $0 Membership Contact Info Same As Above Practice/Institution Name Practice/Institution Address City State ZIP Practice Phone Meeting Registration Registration Categories Fees Member - Physician $75 $100 Member - Nonphysician Provider $50 $75 Nonmember - Physician $125 $150 Nonmember - Nonphysician Provider $100 $125 Student $0 $0 Fellow $0 $0 Resident $0 $0 Special Registration — Nurses In Medical Systems Nurse Employee of RAL Member $25 Industry Employee - Supporting Industry Employee whose company is already supporting RAL $175 Industry Employee - Non-Supporting Industry Employee whose company is NOT already supporting RAL $1,250 Your submission will need to be approved prior to confirmation of your registration. Approval may be based on current Industry support. To find out if your company is currently supporting RAL please contact Brittany Gyuricza in the Registration Department at (847) 264-5963 or by email at email@example.com. TOTAL REGISTRATION FEE: The RAL require full payment for registration fees by check or credit card. Payment Information (must be made in U.S. dollars) CheckCredit Card --Select Card-- Visa MasterCard American Express If paying by check, make check payable to: Rheumatology Alliance of Louisiana Mail payment to: Rheumatology Alliance of Louisiana Two Woodfield Lake 1100 E. Woodfield Road, Suite 350 Schaumburg, IL 60173 I have read, understood and agree to the electronic delivery of the data collected and payment amount. SIGNATURE: By selecting “I Agree” I represent and acknowledge that: I have read, understood, and consented to electronic delivery of the data collected and payment entered above. I have granted authorization to RAL in association with WJ Weiser & Associates, Inc. to charge the amount indicated on the credit card provided. I am the authorized user of the credit card listed above and that the associated information entered (account holder name, account number, billing address, etc.) is accurate. I intend the act of selecting “I Agree” to be my legal signature to this agreement. Enter in the Following Security Code: 969190 This question is for testing whether you are a human visitor and to prevent automated spam submissions. Registration Cancellation and Refund Policy Registration refund requests must be submitted in writing to the RAL Executive Office no later than 7/18/2019. All refund requests will be subject to a $10 processing fee. No refunds will be made after 7/18/2019.